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Topic: Balance Billing (Read 3681 times)

I have a few questions regarding multiple procedure payment reductions ("MPPR").

1) When a Medicare payer reduces an ASC claim by using MPPR, is the ASC allowed to balance bill the patient the difference?

2) When a commercial payer reduces an ASC claim by using MPPR for a non-contracted provider, is the ASC allowed to balance bill the patient the difference?

3) Are MPPR rates typically 100-50?

I have ASC claims reduced using MPPR at rates of 100-25-10, then the non-contracted commercial payer sent EOB's to the patients and payer representing that the patient is not responsible for the difference between the reduced amounts and the provider's billed charges and the provider cannot balance bill. I was informed by the non-contracted commercial payer that they consider any balance billing after MPPR to be unjust enrichment by the provider, so they do this.

I have ASC claims reduced using MPPR at rates of 100-25-10, then the non-contracted commercial payer sent EOB's to the patients and payer representing that the patient is not responsible for the difference between the reduced amounts and the provider's billed charges and the provider cannot balance bill. I was informed by the non-contracted commercial payer that they consider any balance billing after MPPR to be unjust enrichment by the provider, so they do this.

Any comments would be appreciated.

Thanks,

If the provider is out of network and it is a commercial payer the provider can bill the patient. If it is a Medicare plan then the provider must be enrolled with Medicare (participating or non-participating). If it is a Medicaid plan then you must check the state laws. But a commercial plan thru an employer, or other private plan, the patient can be billed.

How do you handle? We are seeing this over and over with one insurance carrier in particular.

Provider is non-participating with commercial insurance and patient is billed full balance. Patient has received an EOB showing ONLY co-insurance or deductible as PR and a code/note that $XX is non-allowed. The EOB does NOT show the patient is responsible for this as well.

Patient contacts insurance to dispute the balance statement received from provider. Insurance tells patient they are only responsible for what is shown as PR. Patient refuses to pay the full balance due.

Provider legally can balance bill and will pursue legal suit. It seems this is the only option at this point as all collection efforts (including debt collection) has no result.

Provider is non-participating with commercial insurance and patient is billed full balance. Patient has received an EOB showing ONLY co-insurance or deductible as PR and a code/note that $XX is non-allowed. The EOB does NOT show the patient is responsible for this as well. 17

There is not enough info.. did you bill with an AOB? It almost sounds like the claim was processed as an "in network" was there an "allowable"? There's simply not enough info to really advise here.

It has been years since I have dealt with billing an out of network insurance for a patient, so I have a question...why bill the insurance at all, if not contracted with them? Isn't that just a courtesy to the patient? Why not collect payment in full at TOS, give the patient a receipt, and let them file a claim on their own, to recoup back what they can, if anything? Or is that not allowed anymore?

If no contract exists then the provider can bill for the entire billed amount minus any payment made. So even though they processed as in network, with the absence of a contract the patient is responsible for the entire amount if that is what the provider wishes to do.